PROCEDURE BANDING LIST EFFECTIVE: 21 April 2012 Whilst APHA believes the information to be based on reliable sources, no warranty is given as to its accuracy and the persons relying on the information do so at their own risk. APHA and its employees disclaim all liability to any person relying on the information contained in its communication in respect of any loss or damage (including consequential loss or damage) which may be suffered or arise directly as a consequence or in respect of the use of or reliance on such information. Summary of Changes Procedure Banding Amended 21 April 2012 1
EXPLANATORY NOTES TO APHA PROCEDURE BANDING LIST: 1. Procedures marked with a (B) or "(C)" in the Status column denote Type B (Day Only) procedures or Type C (Exclusion) items. The non-band specified items listed in the Procedure Banding Manual will qualify for day benefits at the level of Band 2, 3 or 4 depending on anaesthetic type and where applicable, theatre time. If a non-band specific Type B procedure does involve anaesthetic or theatre times the minimum benefit is the benefit for Band 1 treatment. Band 2: means procedures (other than Band 1) carried out under local anaesthetic with no sedation. Band 3: means procedures (other than Band 1) carried out under general or regional anaesthesia or intravenous sedation where the theatre time, being the actual time in theatre, is less than one hour Band 4: means procedures (other than Band 1) carried out under general or regional anaesthesia or intravenous sedation where the theatre time, being the actual time in theatre, is one hour or more. Continuous period of hospitalisation, for the purpose of counting days of hospital treatment, includes any two periods during which a patient was, or is, receiving hospital treatment as a patient at a hospital whether or not the same hospital, where the periods are separated from each other by a period of not more than 7 days during which the patient was not receiving hospital treatment as a patient at any hospital. CERTIFIED TYPE C PROCEDURE Definition Clause 7 Schedule 3 Same Day Accommodation Private Health Insurance Benefit Requirements) Rules 2011 amended 1 November 2011 - Federal Register of Legislative Instruments F2011L02160 Note: Type C procedures are procedures that do not normally require hospital treatment. (1) Benefits for day only accommodation are payable for patients receiving a Type C procedure only if certification under subclause (2) is provided. (2) Certification must be provided as follows the medical practitioner providing the professional service must certify in writing that: (a) because of the medical condition of the patient specified in the certificate; or (b) because of the special circumstances specified in the certificate, it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that does not include part of an overnight stay. Summary of Changes Procedure Banding Amended 21 April 2012 2
ADVANCED SURGICAL: Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 (1 November 2011) Federal Register of Legislative Instruments F2011L02160 (1) Advanced Patient has the meaning given by this clause. (2) A patient is taken to be an advanced surgical patient upon admission to a hospital: a) From and including the day before a professional service of the type identified by the item number in the MBS which is specified in subclause (3) is rendered to the patient at that hospital, unless the particular advanced surgical procedure to be rendered is recognised as requiring a longer pre-operative period; or b) If a longer pre-operative period than that referred to in paragraph (a) is required, from and including the day of admission of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or c) If the advanced surgery is rendered to a patient during an admission, from the day the advanced surgery involving a professional service of the type mentioned in paragraph (a) is performed (not the day before). Note: The effect of the reference in subclause 2 (a) to a professional service, being a service for which a Medicare benefit is payable, is that a professional service must have been provided to the patient for the minimum benefit to apply (3) The item numbers for this clause are only those items which have a fee in the MBS greater than $837.05 SURGICAL: Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 (1 November 2011) Federal Register of Legislative Instruments F2011L02160 (1) Patient has the meaning given by this clause. (2) A patient shall be taken to be a surgical patient upon admission to a hospital from and including: a) the day before a professional service of the type identified by the item number in the MBS which is specified in subclause (3) is rendered to the patient at that hospital, unless the particular surgical procedure to be rendered is recognised as requiring a longer pre-operative period; or b) If a longer pre-operative period is required, from and including the day of admission of the patient for the purpose of providing the professional service of the type mentioned in paragraph (a); or c) If the surgery is rendered to a patient during an admission, from the day the surgery involving a professional service of the type mentioned in paragraph (a) is performed (not the day before). Summary of Changes Procedure Banding Amended 21 April 2012 3
Note: The effect of the reference in subclause 2 (a) to a professional service, being a service for which a Medicare benefit is payable, is that a professional service must have been provided to the patient for the minimum benefit to apply (3) The item numbers for this clause are only those items which have a fee in the MBS within the range of $249.26 to $837.05 OBSTETRIC PATIENT Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 (1 November 2011) Federal Register of Legislative Instruments F2011L02160 (1) In this schedule, obstetric patient has the meaning given by this clause: (2) A patient shall be taken to be an obstetric patient during an admission to a hospital from and including: (a) Whichever is the earlier of: (i) the day on which the patient commences labour leading to delivery in that hospital or (ii) the day on which a professional service with the item number 16406, 16515; 16518; 16519; 16522 (excluding caesarean) or 16525, 16527 or 16528 is rendered to the patient in that hospital or (b) If the circumstances in paragraph (a) do not apply, the day before a professional service with the item number 16520 and 16522 (including caesarean) is rendered to the patient at that hospital, unless the particular obstetric procedure to be rendered is recognised as requiring a longer pre-operative period (c) The day on which the professional service with the item number 82120 or 82125 is rendered to the patient by a participating midwife. (3) In this clause, the item numbers specified are the item numbers in the general medical services table. PSYCHIATRIC PATIENT Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 (1 November 2011) Federal Register of Legislative Instruments F2011L02160 In this schedule a Psychiatric Patient is a patient in a hospital who is admitted for the purposes of undertaking a specific psychiatric treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient s disease, injury or condition. Note: If a patient is receiving psychiatric treatment that is not under a specific psychiatric treatment program, the patient is taken to be in the category of other patient. Summary of Changes Procedure Banding Amended 21 April 2012 4
REHABILITATION PATIENT Definition from Schedule 1 Overnight Accommodation Private Health Insurance (Benefit Requirements) Rules 2011 (1 November 2011) Federal Register of Legislative Instruments F2011L02160 In this schedule, a Rehabilitation Patient is a patient in a hospital who is admitted for the purposes of undertaking a specific rehabilitation treatment program that is deemed by the insurer to be relevant and appropriate for the treatment of the patient s disease, injury or condition. Note: If a patient is receiving rehabilitation treatment that is not under a specific rehabilitation treatment program, the patient is taken to be in the category of other patient. OTHER: In this schedule other patient is deemed to be a patient at a hospital who is receiving any treatment that involves part of an overnight stay, but who is not: an advanced surgical patient, a surgical patient, an obstetric patient, a psychiatric patient or a rehabilitation patient. Note: A patient receiving hospital treatment that is palliative care as described in Item 1 of the table in subsection 72-1(2) of the Act is deemed to be in the category of other patient. OVERNIGHT BENEFITS IN RELATION TO CERTIFIED PROCEDURES: Definition from Schedule 1 Part 3 Private Health Insurance (Benefit Requirements) Rules 2011 (1 November 2011) Federal Register of Legislative Instruments F2011L02160 (1) Minimum benefits for overnight accommodation are payable for patients receiving a Type B procedure only if certification under subclause (2) is provided. (2) Certification must be provided as follows: a. The practitioner providing the Type B procedure; or b. A professional employed by a hospital who is involved in the provision of the procedure provided by that hospital Must certify in writing that: c. Because of the medical condition of the patient specified in the certificate; or d. Because of the special circumstances specified in the certificate, Summary of Changes Procedure Banding Amended 21 April 2012 5
it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay. OVERNIGHT BENEFITS IN RELATION TO CERTIFIED TYPE C PROCEDURES Definition from Schedule 1 Part 3 Private Health Insurance (Benefit Requirements) Rules 2011 (1 November 2011) Federal Register of Legislative Instruments F2011L02160 (1) Minimum benefits for overnight accommodation are payable for patients receiving a certified Type C procedure only if: (a) certification has first been provided for the Type C procedure in accordance with Clause 7 of Schedule 3; and (b) certification under subclause (2) is also provided. (2) Certification must be provided as follows the practitioner providing the certified Type C procedure must certify in writing that: (a) Because of the medical condition of the patient specified in the certificate; or (b) Because of the special circumstances specified in the certificate, it would be contrary to accepted medical practice to provide the procedure to the patient unless the patient is given hospital treatment at the hospital for a period that includes part of an overnight stay. 2. BUNDLED ENDOSCOPY PROCEDURES UNDERLYING PROCEDURE BANDS Endoscopy procedures have been paid on a case based arrangement for many years. The bands noted below are for use as a default band where HPPAs are silent on how benefits for overnight patients undergoing these procedures are to be paid or where there is no HPPA. These bands are noted in BLUE in the Banding Schedule accompanied by a #. An explanatory note, also in blue italic and commencing with # is noted in the description column at the end of the MBS description of procedure. 30473 Band 1 30475 Band 2 30476 Band 1 30478 Band 1 32072 Band 1A 32075 Band 2 32078 Band 2 32081 Band 3 Summary of Changes Procedure Banding Amended 21 April 2012 6
32084 Band 1 32087 Band 1 32090 Band 2 32093 Band 3 32094 Band 3 32095 Band 1 3. 9A Denotes a Band lower than 9 but higher than 8 4. Item No 37203 TURP Where a bipolar electrode is used the NPBC recommended at its October 2006 meeting, that the additional net cost of the use of this device of $277 be recognised as an add on to the existing Band 5. 5. New Procedures are clearly identifiable by the red font in the Excel Spreadsheet Amended Descriptions/classifications are clearly identifiable by the green font in the Excel Spreadsheet. A 2.0% fee increase was applied to MBS items (except Diagnostic Imaging, Pathology, Radiation Oncology; items) from 1 November 2011 and fees noted in this update reflect MBS fees as of 1 November 2011. 6. If a Band has a # after the number, please refer to the item description as it denotes that the National Procedure Banding Committee has attached a comment to the Band for example Item 38220 2# = # Only for use with Multiple Procedure Claims GENERAL REMINDER TO HOSPITAL BILLING STAFF 7. When billing for more than one item number, hospitals are advised to check the MBS descriptors to ensure that no restrictions apply two examples of such restrictions are noted in italics below 48948 Orthopaedic: Shoulder, arthroscopic surgery of, involving any 1 or more of: removal of loose bodies; decompression of calcium deposit, debridement of labrum, synovium or rotator cuff; or chondroplasty not being a service associated with any other arthroscopic procedure of the shoulder region 36812 Urological: cystoscopy with urethroscopy, with or without urethral dilatation, not being a service associated with any other urological endoscopic procedure on the lower urinary tract except a service to which item 37327 applies. Summary of Changes Procedure Banding Amended 21 April 2012 7
Please Note: Special Arrangements Transitional Period Where the description, item number or schedule fee for an item has been amended, the following rule will apply:- Where an item refers to a service in which treatment continues over a period of time in excess of one day and the treatment commenced before 1 November 2011 and continues beyond that date, the general rule is that the 1 November 2010 level of fees and benefits would apply. MBS BOOK With effect from the 1 November 2008 edition, the MBS book is no longer routinely available in hard copy. For the information of users, an electronic copy of the 1 November 2011 MBS book is provided on the CD circulated with the 1 November 2011 Procedure Banding update Summary of Changes Procedure Banding Amended 21 April 2012 8
SUMMARY OF CHANGES The 1 March 2012 changes to the MBS are summarised on the following pages. Please note this list only contains items which have been amended or added since the last update issued on 1 March 2012 SUMMARY OF CHANGES Updated 21 March 2012 & amended 21 April 2012 re 42738 PHI Circular 17/11 of 21 March 2012 contained advice regarding classifications for the two new bands 42738 and 42739 which were added to the MBS with effect from 1/3/2012. Commonwealth Classifications for these two item numbers are noted below. Please note reclassification of 42738 from Type C to Type B with effect from 21/4/2012 As per PHI Benefit Requirements Amendment Rules 2012 (No 3) F2012L00905 dated 20/4/2012 and to take effect the day after registration i.e. 21/4/2012 CLASSIFICATION OF NEW BANDED ITEMS ADDED TO MBS - 1 MARCH 2012 New Item Recommended Band Comments Classification 42738 3 Interim Band Please note Originally classified by DoHA as Type C but amended by PHI Benefit Requirement Amendment Rules 2012 (No 3) (issued 20 April 2012 F2012L00905) to 42739 3 Interim Band (amended from Type C (21/4/2012) CLASSIFICATION CHANGES EFFECTIVE 21 MARCH 2012 Item Number Band New Classification 32215 No Band 32217 2 36660 3 36663 4 36664 4 36665 No Band attendance item Medical Medical TYPE A TYPE A Medical Summary of Changes Procedure Banding Amended 21 April 2012 9
36666 3 TYPE A 36667 3 36668 3 Medical Medical Summary of Changes Procedure Banding Amended 21 April 2012 10